GC Schalkwijk | GPs | Haarlem Pharmacy

Residents who have just moved to Haarlem and fall within postal code areas 2034 to 2037 can register using the following link Subscribe

Registration can also be done via the following form

You can print the registration form and hand it in to the assistants on the 2nd or 3rd floor, after which the assistant will give you further explanation.

Last Page

First name *

Initials *

Surname *

Maiden name

Email address *

Phone number *

Gender *

Date of birth *

Place of birth *

Emergency contact name

Emergency contact mobile number

Street name *

House number *

Addition

Postcode *

Location *

BSN *

Health insurer *

Policy number *

Pharmacy (new) *

Previous GP *

Place name previous GP

Desired registration date *

Comments

I agree to register with this practice. *

Yes

I give permission to the practice to request my record from my previous GP/carer. *

Yes

I consent to the exchange of my medical data with healthcare partners such as the emergency department, hospital and pharmacy. *

Yes